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Maximize your government business potential

From enrollment through risk adjustment, augment your core administration system with features to automate processing.

Power-up your government line of business

We have the solutions you need to extend functionality of your core system, fully integrated and immediately effective.

Meeting the complex data processing and compliance requirements of Medicare Advantage, managed Medicaid and Commercial Exchanges in a timely manner is critical to your success. Our TriZetto Elements® suite of capabilities extends the functionality of your core system with the features you need, providing critical capabilities from enrollment through risk adjustment to efficiently drive these lines of business forward.

Our standalone solutions integrate well together, with Facets®, QNXT™ and other core systems. With Elements products, it is easy to share information and speed processing.

With Elements you can:

  • Track and transform encounter data.
  • Automate encounter, Risk Adjustment Processing System (RAPS) and risk adjustment data submission.
  • Facilitate interactions between your plan and Centers for Medicare and Medicaid Services (CMS).
  • Maximize reimbursements.
  • Accelerate response to regulatory changes.
  • Improve acceptance rates.
  • Reduce the risk of potential CMS penalties.

Elements product suite

  • Trizetto® Enrollment Administration Manager and Trizetto® Enrollment Administration Manager Workflow

    TriZetto® Enrollment Administration Manager (EAM), powered by TriZetto® Enrollment Administration Manager Workflow, helps health plans move from enrollment to acceptance. EAM streamlines the process to enroll your members in Medicare Advantage. The product is constantly updated to reflect CMS regulatory changes and can pass data to both the Facets® and QNXT™ platforms, making it a critical part of a complete solution. The workflow manages the overall enrollment process, improving visibility and tracking throughout the enrollment lifecycle.

    TriZetto Enrollment Administration Manager and TriZetto Enrollment Administration Manager Workflow enable you to:

    • Initiate enrollment changes, PBP changes, and other member changes from multiple channels including batch, web service and user entry.
    • Leverage comprehensive validations of enrollment and member change transactions, streamlining enrollment processes to maximize acceptance rates and minimize unnecessary manual work.
    • Automate member eligibility verification and related member correspondence directly with CMS Real-Time API or Batch Eligibility Query (BEQ).
    • Automate OEC election retrieval, processing and reconciliation with CMS Real-Time API.
    • Comply with Part C and Part D enrollment reporting requirements.
    • Enable the robust processing of daily and special Transaction Reply Reports (TRR) when applying member updates and auto-triggering member correspondence.
    • Enforce enrollment related CARA Legislation.
    • Gain a clear view of daily enrollment work in progress.
    • Enable and maintain compliance with CMS regulations.
    • Automate the routing and assignment of work items based on specific roles, queues and priorities for issue enrollment and resolution.
    • Integrate enrollment data with QNXT, Facets or other third-party core administration applications for billing, claims processing and member services.
  • Financial Reconciliation Manager

    TriZetto® Financial Reconciliation Manager (FRM) streamlines and automates the process of reconciling the amount plans have been paid by CMS with the member payments received, comparing plan and CMS membership data to flag and determine the impact of discrepancies. The system prioritizes inconsistencies with the greatest financial impact and provides key data to resolve discrepancies quickly.

    With Financial Reconciliation Manager you can:

    • Use one system for Medicare Part C and Part D payment reconciliation by member or Plan/PBP.
    • Identify eligibility, member demographic, special status, low income, out of area and payment discrepancies.
    • Correct your plan’s internal data system and submit corrections to CMS via the Retroactive Processing Center.
    • Assist the management of work assignments, workflow management and discrepancy aging.
    • Ensure that your organization has the tools to remain in compliance with CMS regulations for financial reporting.
  • Trizetto® Encounter Data Manager™

    TriZetto® Encounter Data Manager™ (EDM) supports submission requirements and provides functionality to help our clients meet applicable compliance expectations, improve revenue and reduce overhead. EDM provides a configurable and scalable encounter management solution that produces agency compliant encounter transactions, while enforcing submission rules to help prevent non-compliant transactions from being submitted to CMS, Commercial Exchange or state agencies.

    With Encounter Data Manager you can:

    • Reduce costs associated with inaccurate or incomplete data by providing quick and timely resolution of submission errors.
    • Capture accurate data from multiple sources.
    • Gauge potential financial mismatches and potential loss of revenue from CMS, Commercial Exchange or state agencies.
    • Reduce the need for complex customization and state-specific solutions with built-in client configuration.
    • Access aggregated and detailed encounter management information.
    • Enhance business processes and provide transparency in the encounter life-cycle.
  • Trizetto® Claims Data Manager

    TriZetto® Claims Data Manager (CDM) streamlines and simplifies your health plan’s requirement for submitting timely RAPS data for Medicare Advantage members. CDM is a configurable and scalable solution that produces agency compliant RAPS transactions, while enforcing submission, filtering and formatting rules to reduce non-compliant transactions from being submitted to CMS.

    With Claims Data Manager you can:

    • Edit pre-submissions for improved CMS acceptance.
    • Convert claims data into RAPS format.
    • Create batch files for Palmetto Customer Service and Support Centre (CSSC).
    • Load and reconcile RAPS response files.
  • Trizetto® Risk Score Manager

    TriZetto® Risk Score Manager (RSM) analyzes data submitted by Claims Data Manager and Encounter Data Manager to calculate the risk scores your health plan can expect to be reimbursed based on the diagnoses submitted to CMS. It reconciles scores against monthly CMS data from the RAPS response files. With RSM, your health plan gains visibility into risk scores, which allows you to better forecast payments from CMS. RSM reconciles your RAPS and EDPS submissions to ensure the data submitted to CMS is accurate for both. It identifies missing adds or deletes by comparing RAPS Reply and MAO-004 files from CMS.

    With Risk Score Manager you can:

    • Identify member Hierarchical Condition Category (HCC) and Rx HCC by payment year and data collection.
    • Compare HCC information to CMS information to identify discrepancies.
    • Calculate Part C and Part D risk scores using plan, CMS demographics and HCC data.
    • Determine claim/diagnosis level RAPS in cases when CMS is missing accepted HCCs/Rx HCCs.
    • Provide detailed risk score and HCC-related management reports.
    • Utilize the RAPS response files and EDPS MAO-004 reports to compare the latest disposition of diagnosis codes at the member level.
  • Trizetto® Risk Adjustment Manager

    TriZetto® Risk Adjustment Manager (RAM) aggregates claims, pharmacy and demographic data and runs it through algorithms to identify potential conditions a member may have. The results of the chart reviews—adds and deletes—are entered into RAM and extracted for submission via RAPS and EDPS to improve the overall accuracy of the data submitted to CMS. RAM runs a series of algorithms to identify additional diagnoses appropriate for members based on their claims history. With that information, your health plan can take action if additional diagnoses have been made by providers. With the data collected by RAM, health plans can request CMS to adjust risk scores for their Medicare Advantage members.

    With Risk Adjustment Manager you can:

    • Automate key processes from assessment of member data through creation of reports that support RADV audits.
    • Identify potential diagnoses by combining claims, pharmacy and demographic data.
    • Manage the workflow related to organizing prospective candidates for adjusted risk scores and requesting changes.
    • Track chart audit results on both Medicare Part C and Part D risk scores.
    • Conduct assessments on members by evaluating their health prior to claims submission.
  • Trizetto® Risk Adjustment Manager for Exchanges

    TriZetto® Risk Adjustment Manager for Exchanges (RAMX) is a comprehensive workflow-based solution that helps health plans automate regulatory compliance and submission to the CMS EDGE server by aggregating patient data and identifying clinical suspects for risk review, coding resolution and formatting prior to submission. Applying advanced algorithms against claims data, pharmacy data, patient demographics, and care delivery demographics, RAMX enables payers to effectively recognize and address indications of inaccurate or unspecified patient conditions. Once your health plan has made the appropriate coding modifications to increase the accuracy and quality of the clinical data, files are automatically formatted for direct submission to the EDGE server. RAMX can also be integrated with your plan’s current solution for suspect generation.

    With Risk Adjustment Manager for Exchanges you can:

    • Increase the quality and accuracy of data submitted to CMS.
    • Identify clinical suspects for risk review and coding resolution.
    • Support regulatory compliance and timely submission of data to the EDGE server.
    • Detect issues for resolution and restitution prior to a RADV audit.
    • Allow suspect data comparisons at medical group, IPA and physician levels to identify provider education opportunities.
  • Trizetto® Pharmacy Data Event Manager

    TriZetto® Pharmacy Data Event Manager (PDEM) automates the workflow around pharmacy claim rejections from CMS, providing a clear view into the rejection type and ensuring they are corrected. PDEM identifies the issues, determines the reasons for rejection and corrects them for resubmission.

    With Pharmacy Data Event Manager you can:

    • Pre-screen records format and content per CMS edit criteria.
    • Create a CMS PDE file format for record submission.  
    • Track and update adjustment and deletion records for resubmission.
    • Import return files from CMS and Drug Data Processing System (DDPS) and update record statuses and error codes.
    • Allow users to edit and resubmit records from within the application.
    • Manage reports by file, batch, status, error code and plan benefit package.
  • Trizetto® Rx Reconciliation Manager

    TriZetto® Rx Reconciliation Manager (RxM) is a tool that helps plans fully understand the financial and reconciliation activity of CMS with regard to Medicare Part D. With this visibility, your plan can better anticipate payment adjustments and make changes for Part D benefits in the future.

    With Rx Reconciliation Manager you can:

    • Calculate and report on Medicare Part D retrospective reconciliation measures including low income cost sharing subsidy, reinsurance subsidy payment and risk corridor.
    • Harness the data processing and tracking capabilities of Financial Reconciliation Manager (FRM) for prospective revenue reconciliation and PDE Data Manager (PDEM) for PDE data processing, submission and management.

Related thinking

Lines of business


Comprehensive, flexible and scalable core administrative solutions that enable the digital transformation required for success in the commercial market.

Individual & Small Group

Supports the economic advantage and efficiency needed to administer an individual line of business and participate in public and private insurance exchanges.


Flexible IT solutions to address requirements with customizable functionality.


Functionality that adapts to meet the complexities and demands of the Medicare Advantage market.


Functionality that adapts to meet the complexities and demands of the Managed Medicaid market.


Flexible solutions to coordinate multiple compliance requirements and ease administration burdens.

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